Cirrhosis 01

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All About Cirrhosis

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Cirrhosis 01

  1. 1. "With ordinary talent andextraordinary perseverance, allthings are attainable."- Thomas E. Buxton"Achievement is connectedwith action, not in genes..…!”- Conrad Hilton
  2. 2. Pathology ofHepatitis & CirrhosisVenkatesh Murthy Shashidhar Associate Professor of Pathology Fiji School of Medicine A Commitment to Excellence…
  3. 3. Normal Liver
  4. 4. Autopsy 1.5 kg, wedge shape 4 lobes, Right, left, Caudate, Quadrate. Double blood supply Hepatic arteries Portal – Venous blood Acini / Portal triad. Lobules – central. V
  5. 5. Normal Liver - Infant
  6. 6. CT Upper abdomen - Normal
  7. 7. VHP- Upper abdomen
  8. 8. Normal Liver - Microscopy
  9. 9. Liver Functions: Metabolism – Carbohydrate, Fat & Protein Secretory – bile, Bile acids, salts & pigments Excretory – Bilirubin, drugs, toxins Synthesis – Albumin, coagulation factors Storage – Vitamins, carbohydrates etc. Detoxification – toxins, ammonia, etc.
  10. 10. Jaundice Yellow discoloration of skin & sclera due to excess serum bilirubin. >40umol/l, (3mg/dl) Conjugated & Unconjugated types Obstructive & Non Obstructive (clinical) Pre-Hepatic, Hepatic & Post Hepatic types Jaundice - Not necessarily liver disease *
  11. 11. Pathology of Hepatitis
  12. 12. Hepatitis: Hepatitis: Inflammation of Liver Viral, Alcohol, immune, Drugs & Toxins Biliary obstruction – gall stones. Acute, Chronic & Fulminant - types Viral Hepatitis –  Specific – Heptitis A, B, C, D, E, & other  Systemic - CMV, EBV, other.
  13. 13. Pattern of Viral Hepatitis: Carrier state / Asymptomatic phase Acute hepatitis Chronic Hepatitis  Chronic Persistent Hepatitis (CPH)  Chronic Active Hepatitis (CAH) Fulminant hepatitis Cirrhosis Hepatocellular Carcinoma
  14. 14. Acute - Hepatitis - Chronic
  15. 15. Acute Hepatitis: Swelling and Apoptosis Piecemeal or Bridging, panacinar necrosis Inflammation – lymphocytes, Macrophages Ground glass hepatocytes – HBV Mild fatty change – HCV Portal inflammation and Cholestasis
  16. 16. Fulminant Hepatitis: Hepatic failure with in 2-3 weeks. Reactivation of chronic or acute hepatitis Massive necrosis, shrinkage, wrinkled Collapsed reticulin network Only portal tracts visible Little or massive inflammation – time More than a week – regenerative activity
  17. 17. Chronic Hepatitis: Persistent & Active types. CPH/CAH Lymphoid aggregates Periportal fibrosis Necrosis with fibrosis – bridging fibrosis. Cirrhosis – regenerating nodules.
  18. 18. Acute viral Hepatitis:
  19. 19. Acute viral Hepatitis:
  20. 20. Acute viral Hepatitis:
  21. 21. Acute viral Hepatitis C:
  22. 22. Liver Biopsy – CPH:
  23. 23. Liver Biopsy – Cirrhosis
  24. 24. Viral Hepatitis: Microbiology Virus Hep-A Hep-B Hep-Cagent ssRNA dsDNA ssRNATransm. Feco-oral Parenteral ParenteralCarrier None 0.1-1.0% 0.2-1.0%stateChronic None 5-10% >50%Hepatitis
  25. 25. Pathology of AlcoholicLiver Disease
  26. 26. Alcoholic Liver Injury: Ethyl alcohol : Common cause of acute/Chronic liver disease Alcoholic Liver disease - Patterns  Fatty change,  Acute hepatitis (Mallory Hyalin)  Chronic hepatitis with Portal fibrosis  Cirrhosis, Chronic Liver failure All reversible except cirrhosis stage.
  27. 27. Alcoholic Liver Injury: Pathogenesis Acetaldehyde – metabolite – hepatotoxic Diversion of metabolism – fat storage. Oxidation of ethanol NAD to NADH. NAD is required for the oxidation of fat.. Increased peripheral release of fatty acids. Inflammation, Portal bridging fibrosis Stimulates collagen synthesis – fibrosis. Micronodular cirrhosis.
  28. 28. Alcoholic Liver Damage
  29. 29. Alcoholic Fatty Liver
  30. 30. Steatosis in Alcoholism
  31. 31. Alcoholic Fatty Liver
  32. 32. Alcoholic Fatty Liver
  33. 33. Cirrhosis in Alcoholism
  34. 34. Alcoholic Cirrhosis
  35. 35. Bilirubin Metabolism•Blood •Conjugated & Conjugated•Urine – Urobilinogen•Stool – Stercobilin
  36. 36. Common Causes of Jaundice Pre Hepatic (Acholuric) - Hemolytic  Unconjugated/Indirect Bil, pale urine Hepatic – Viral, alcohol, toxins, drugs  Liver damage - unconjugated  Swelling, canalicular obstruction - Conjugated Post Hepatic (Obstructive) – Stone, tumor  Conjugated/Direct Bil, High colored urine,
  37. 37. Jaundice
  38. 38. Jaundice
  39. 39. ‘Time’ is the best kept secret of the rich..!– Jim Rohn
  40. 40. Pathology of AlcoholicLiver Disease
  41. 41. Definition:1. Diffuse disorder of liver characterised by;2. Complete loss of normal architecture,3. Replaced by extensive fibrosis with,4. Regenerating parenchymal nodules.
  42. 42. Introduction Cirrhosis is common end result of many chronic liver disorders. Diffuse scarring of liver – follows hepatocellular necrosis of hepatitis. Inflammtion – healing with fibrosis - Regeneration of remaining hepatocytes form regenerating nodules. Loss of normal architecture & function.
  43. 43. Normal Liver
  44. 44. Cirrhosis
  45. 45. Normal Liver Histology CVPT
  46. 46. CirrhosisFibrosisRegenerating Nodule
  47. 47. Etiology of Cirrhosis Alcoholic liver disease 60-70% Viral hepatitis 10% Biliary disease 5-10% Primary hemochromatosis 5% Cryptogenic cirrhosis 10-15% Wilson’s, α1AT def rare
  48. 48. Pathogenesis: Hepatocyte injury leading to necrosis.  Alcohol, virus, drugs, toxins, genetic etc.. Chronic inflammation - (hepatitis). Bridging fibrosis. Regeneration of remaining hepatocytes Proliferate as round nodules. Loss of vascular arrangement results in regenerating hepatocytes ineffective.
  49. 49. Cirrhosis Features: Liver Failure Parenchymal regeneration but why …..??. Portal obstruction, Porta systemic shunts… Portal hypertension, Splenomegaly Jaundice, Coagulopathy, hypoproteinemia, toxemia, Encephalopathy,
  50. 50. Pathogenesis of Hepatic Encephalopathy BRAIN Porta systemic shunts LIVER Toxic N2 metabolites From Intestines
  51. 51. Micronodular cirrhosis
  52. 52. Ascitis in Cirrhosis
  53. 53. Ascitis in Cirrhosis
  54. 54. Micronodular cirrhosis:
  55. 55. Micronodular cirrhosis:
  56. 56. Alcoholic Hepatitis
  57. 57. Macronodular Cirrhosis
  58. 58. Liver Biopsy – Cirrhosis
  59. 59. Liver Biopsy – Cirrhosis:
  60. 60. Nutmeg Liver-Cardiac Sclerosis
  61. 61. Clinical Features Hepatocellular failure.  Malnutrition, low albumin & clotting factors, bleeding.  Hepatic encephalopathy. Portal hypertension.  Ascites, Porta systemic shunts, varices, splenomegaly.
  62. 62. Bleeding in Liver disease: vitamin K – in liver gamma-carboxyglutamic acid – for coagulation factors II, VII, IX, and X. Liver disease  factor VII is the first to go  so the defect will appear initially in the extrinsic pathway, i.e., abnormal PT. When severe it affects both pathways.
  63. 63. Cirrhosis ClinicalFeatures
  64. 64. Gynaecomastia in cirrhosis
  65. 65. Porta-systemic anastomosis: Prominent abdominal veins.
  66. 66. MRI Cirrhosis
  67. 67. Complications: Congestive splenomegaly. Bleeding varices. Hepatocellular failure.  Hepatic encephalitis / hepatic coma. Hepatocellular carcinoma.
  68. 68. Hepatocellular Carcinoma
  69. 69. Conclusions: Common end result of diffuse liver damage. (Viral hepatitis, Alcohol, congenital, drugs, toxins & Idiopathic) Characterised by diffuse loss of architecture. Fibrous bands & regenerating nodules distort and abstruct blood flow. (inefficient function) Hepatocellular insufficiency & portal hypertension. Shrunken, scarred liver, ascitis, spleenomegaly, liver failure, CNS toxicity.
  70. 70. Conclusions: Hepatitis. Hepatitis – Alcohol, Virus (ABCD), Drugs… Hepatocyte damage – inflammation Acute / Chronic (Active / Persistent) Fever, Jaundice, Malaise, Fat intolerance. Complications. Alcohol – NAD, Acetaldehyde – metabolism Fatty liver  Necrosis  Cirrhosis.
  71. 71. Learn from themistakes of others.You cant live longenough to make themall yourself…!

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